Lauren Foley

PTA 2600 Week 1 & 2 Progress Note Analysis

In the review of the information under the objective portion of my patient’s progress note
for weeks 1 and 2, I made a numerical ‘typo’ with my ROM and MMT measurements. The
correct data is: Wk 1: L Knee Flexion 0-94° PROM / Wk 2: L Knee Quads 3/5 MMT
That being said, the patient improved in her left knee flexion by 10°, (from 94 to 104°), and
extension by 8°, (from -10° to -2°). The quadriceps are the primary muscle group that controls
knee extension and the MMT for Week 2 on the left knee was 3/5, since the patient was able to
perform knee extension against gravity with no applied resistance. The left knee hamstrings
MMT remained at 3-/5 since the patient cannot fully flex the knee against gravity within the full
range of motion, due to her limited PROM of 94°. Patient presented with a decrease in her right
hamstrings MMT previously at 4+/5 to 4-/5, test position against gravity with moderate
resistance applied, most likely due to her bothersome back pain. The patient would most likely
present with the prior level of function with the MMT once back pain subsides.
There was a decreased amount of therapeutic exercise for the week 2 progress note due to
the amount of time it took the patient to transfer from EOB to 4WW to perform ADL’s in
bedroom, and also due to the patient’s very slow cadence during gait training. The patient
performed 15min of exercise on the Omni-Cycle however there was minimal change to her vital
signs as a result of low activity tolerance due to LBP even with increased comfort from MHP.

The patient has met the following short/long term functional goals:
1. The patient will perform 5 sets ascending/descending 6” stairs with modified independence
(bilateral handrail) by discharge.
2. The patient will demonstrate L knee AROM 0/100 degrees in order to ascend/descend
stairs by discharge.
3. The patient will safely transfer from STS without assistance and no verbal cueing.

The patient continues to struggle in accomplishing the remaining short/long term goals:
1. The patient will actively participate in 25min of graded therapeutic exercise influenced by
increased activity tolerance and decreased L knee pain.
2. The patient will achieve L LE ROM and Strength WFL in order to normalize gait pattern.
3. The patient will improve L knee PROM to 0° extension and 115° flexion in order to
normalize joint function.

3. The patient has improved her amount of gait distance, stair training with 6” steps and CGA,
and her transfers have improved from Moderate-Minimal Assistance to Supervised Assistance-
SBA. Although the patient has progressed with the stair height, she presents with a lot of fear
while doing them. I think gait training in the community and practicing stepping on curbs will
help play a role in improving her confidence. Despite the LBP that the patient presented with
while performing this progress note, the patient has been able to progress since then, with
increased activity tolerance on the Omni-cycle as well as ambulation distances. Continuing with
therapeutic exercises such as TKE and heel slides, her ROM will only get better which will then
help her get closer to functional ROM in her knee.